XX Congresso da
Associação Junguiana do Brasil

Soma, Psique e Individuação

De 14 a 17 de Junho de 2012

Science and relational psychotherapy: how empirical research can inform our clinical work with early relational trauma – Dra Jean Knox-

In the best traditions of scientific discovery, I shall start with a dream:

A woman dreamt that she was in the sea, in the midst of a number of sharks and people fighting. They were in pairs, with one shark and one person fighting each other. She was not clear if either the shark or the human was a victim- each seemed to be attacking the other. She was terrified that she herself would be attacked, so she sank slowly to the bottom, where she was able to breathe, and stayed there very still and quietly.

 

Her previous therapist had interpreted this as her choosing death over life, an interpretation that reflected that therapist’s belief that innate instinctual drives directly determine the nature of unconscious phantasy (including dreams) and that the dream was an expression of the death instinct in action.

In contrast my view of the dream was that it conveyed the impact on her of her parents’ violent arguments when she was a child- her defence being to withdraw from relationships into a dissociative observer position, to freeze emotionally so as not to draw their rage onto herself. This way of seeing the dream reflected my belief that it is the internalization of real relational experience that creates unconscious fantasy and that a dream such as this represents the patient’s internal working models of such relational patterns, including the emotions of terror and frozen withdrawal she experienced when her parents were fighting. While there are obvious transference implications of this dream, I shall not elaborate on these here, other than to say that my view is that they directly derive from her early relational experience.

These two different interpretations of this dream directly reflect each therapist’s assumptions about the neurobiology and developmental processes that underpin unconscious thought and imagery. So how are we to determine which one of us had the more accurate view of the dream? I do not think it is acceptable to take a post-modern approach and argue that all interpretations are equally valid- I think it really does matter that our theories reflects the accumulating empirical evidence about the ways that the human brain and mind actually do develop and function. Of course there are areas where the jury is still out on this. But it seems to me that there is enough empirical evidence from other disciplines to enable us to show that some of the core psychoanalytic theories about the nature of the human unconscious mind are based on inaccurate and outdated assumptions about neurobiology, genetic inheritance and developmental processes (Bowlby, Fisher & Greenberg 1996, Hamilton 1996, Kitcher 1995, Knox 2010, Schore 1994).

         Specifically, the psychoanalytic view that instinctual drive creates specific unconscious fantasy and the Jungian view of an inherited collective unconscious are both based on an implicit assumption that a ground plan or blueprint of the human psyche is inherited in our genes and that this blueprint contains specific desires, such as the infant’s incestuous or destructive wishes, or the potential for specific types of imagery, such as the archetypes of the collective unconscious.

This kind of “innatism,” a view that the human brain has inherited modules of information, is a profound misunderstanding of the emergent nature of the development of the human mind and brain that is by no means unique to psychodynamic theory. Evolutionary psychologists argue that, through the process of natural selection, the human mind has developed domain-specific, content-rich programs specialized for solving ancestral problems (Barkow, Cosmides & Tooby, 1992; Pinker 1997; Tooby & Cosmides, 2005).There is a wealth of research that indicates that this kind of innatism, inherent in psychoanalytic and Jungian theory, as well as evolutionary psychology, is a profound misunderstanding of emergent epigenetic development processes. To assert that our desires are predetermined by our genetic makeup  fails to reflect the fact that both the physical and psychological- bodies and minds- emerge out of developmental processes that are both self-organizing and highly dependent on the environment and relationships, as Susan Oyama describes in her remarkable book ‘The Ontogeny of Information’ (Oyama, 2000). An emergent model of development has at its core the view that a stream of current experience constantly reshapes and guides the development of the human mind and brain, continuously switching some genetic pathways on and others off in a highly interactive way.

Along similar lines, neuroscientist Terrence Deacon challenges Steven Pinker’s view that language is hard-wired into our brains, in his book ‘The Symbolic Species’, where he argues that language and brain co-evolve, that the environment of spoken language that human infants experience from and even before birth itself shapes the development of the neural pathways of the brain (Deacon, 1997; Karmiloff-Smith, 1992). Developmental studies such as those of Ed Tronick support the view that experience changes genes and brain—that the influence is not just one way. Genes and brains are not static entities but change throughout development:

It is necessary to recognize that experience, genes, and brain, as well as the structures and processes of all three, are not only fundamentally different at different ages, but their constant interplay is also different and makes for qualitative differences in the totality of the biopsychological organization of the individual in each moment of the lifespan. (Tronick, 2007, p. 6).

Neurobiologists such as Panksepp and Panksepp (2000) also play a key part in developing a more accurate epigenetic model of human development and in correcting what they rather poetically described as “the seven sins of evolutionary psychology.” They highlighted one of the most important errors that is central to evolutionary psychology, the view that the human neocortex has “genetically pre-ordained ‘modules’ that generate specific types of psychological strategies” (ibid., p. 108). Panksepp and Panksepp argued that there is a fundamental confusion in this model between the functions of the more recently evolved human neocortex and the much older subcortex that we share with other mammals. Their view is that the human neocortex evolved as a very general and flexible form of intelligence dedicated to general-purpose symbolic processing and that “evolutionary psychologists appear to be seeking specific socio-emotional modules among higher brain functions where the predominant functions may only be general-purpose cognitive/thinking mechanisms” (ibid.p. 111). Evolutionary psychology is a discipline that, I have pointed out, has many conceptual similarities to the innatism inherent in both Freud’s and Jung’s models of the mind (Knox, 2003). An article in the Guardian newspaper on Nov 15th 2010 highlighted the work of a number of scientists who strongly critique this biological determinism, particularly in relation to gender differences.

So an emergent epigenetic model of human development places environmental and cultural influence, especially the earliest relationship with caregivers, right at the heart of human psychological and emotional development and as clinicians we simply have to become aware of the impact of this kind of  empirical evidence on our theoretical models and hence on our clinical practice. The theory the therapist uses really does matter, because in most psychodynamic theories, the model of the mind is closely coupled to and prescriptive of specific clinical techniques. For example, Klein’s view of the nature of unconscious content is not just a theoretical model of the mind but also a prescription for a particular clinical technique, centered on deep and early interpretation, specifically in relation to negative transference as, ultimately, an expression of the death instinct, as Hinshelwood spelled out. He specified this tight link in a Kleinian approach between the theory and clinical practice:

The negative transference is also important on theoretical grounds. Since derivatives of the death instinct are the problem, aggression and destructiveness need to be brought into the transference for investigation and interpretation. (Hinshelwood,1989 p. 16)

 

In so far as this model attributes aggression and destructiveness to innate inherited mental content derived from a supposed biological force called the death instinct, it is based on neurobiological models that are increasingly out of step with the detailed developmental research, such as that of Beatrice Beebe and colleagues. Their work suggests that the unconscious is co-constructed in relational interactions:

In our view representations arise from interactions. We hold a dynamic process transformational model of representations in which a schema is constructed and transformed through the expected moment-to-moment interplay of the two partners.  What is represented is the dynamic interactive process itself (Beebe & Lachmann 2002, p.147-148)

So we cannot just sidestep the issue of neurobiological theory by staying in a hermeneutic bubble dealing with immediate here and now subjective experience. Whether we like it or not we construct theories about the brain processes that underpin the phenomena we see in the consulting room and our clinical interventions derive from those theories we hold about how the brain functions. It seems to me that as clinicians we are faced with a choice between outdated  neurobiological theories-innate mental contents, instinctual drives, and inherited collective unconscious -or contemporary neuroscience, that however tentatively we should use it does give us more accurate working hypotheses about some of the neurbiological and developmental  processes that might underpin the phenomena we see in the consulting room.

But there is, of course a real danger in using neuroscience too simplistically to explain clinical experience. What we need, I think is to construct the most plausible and logical hypothesis to describe how certain clinical phenomena might develop, based on interweaving the evidence from different disciplines. Let me explain what I mean by using as an example some very specific aspects of long-term relational trauma in order to propose a model we can use to integrate clinical knowledge with empirical research from four sources of evidence. These are:

1)                          Clinical phenomena that therapists recognize and agree to be linked with a history of early relational trauma.

2)                          Developmental studies that show the long-term impact of negative attitudes of caretakers to their infants on that infant’s subsequent development.

3)                          Neuroscientific research demonstrating that neural pathways exist that link perception of emotion on another’s face to self-experience.

4)                          Psychotherapy outcome studies that demonstrate the link between relational experience with the therapist and the outcome of the therapy.

 

1) Clinical phenomena

All therapists are constantly confronted with the reality of the powerful unconscious hold that the past can have over our perception of the present, so that we relate to the present as though it were the past. Indeed, the concept of the transference itself is a description of the experience that the past comes alive in the consulting room in the embodied relational patterns and implicit affective interactions that are activated in any new relationship.

One of the most intractable problems we face in the consulting room is that patients who have experienced abuse or long-term relational trauma often seem to persist in describing themselves as disgusting, bad, dirty and all the other words of self-loathing which reflect a deeply painful self-hatred that the person clings to in spite of all attempts to shift it.  This self-blame is, in part, a defensive response to trauma; self-blame narratives, created in imagination and fantasy are attempts to find some meaning in the cruelty, rejection or indifference from those whom we love and on whom we are most dependent. One aspect of these narratives is that the child feels that his or her own vulnerability, naivety and dependence were the cause of the parental rejection and therefore unconsciously condemns and persecutes any such weakness whenever it emerges. That child grows up to believe that it is dangerous to enter into any relationship and that all emotional vulnerability or need for attention will trigger rejection.

This, in itself, can create the sense of self-blame that is so resistant to change through insight. Trauma, especially that which arises in long-term relationships- parent to child, or adult sexual partners, is not just an experience of external events which are painful or distressing. Over time, it also gets right inside the psyche, profoundly damaging the sense of oneself as a subject, with a capacity for agency, which is ours sense that we can  influence and modify the behaviour and attitudes of others towards us. Instead, the person comes to see him or herself as a self-object for the caregiver, with the endless task of meeting that caregiver’s needs and taking endless responsibility for their actions, leading to the state of self-blame I have described.

2) Developmental research.

A baby’s sense of identity comes from the meaning attributed by the mother to his or her actions, which, as Jungian analyst George Hogenson describes ‘bootstraps the infant into the world of adult meaning’ and there are a number of studies that demonstrate this parent-infant interaction that Vygotsky  described as ‘scaffolding’(Tamoepeau & Ruffman 2008).

The argument that early relational experience is an enduring and powerful determinant of psychological and emotional development throughout life is not just an untested hypothesis but is supported by a number of longtitudinal studies (Sroufe & Waters 1977, Broussard & Cassidy 2010.). But the infant’s dependence on key attachment figure to give meaning to his/her actions makes him or her uniquely vulnerable to negative responses from the caregiver. This kind of parental rejection, which may be a mere facial expression of disapproval or even disgust may be entirely unconscious but be regularly repeated and so a core part of the infant’s relational experience.

 For example, Broussard & Cassidy (2010) assessed the attitude of mothers to their newborn babies, using the Neonatal Perception Inventory (NPI), which measures the mother’s perception of her baby compared with her view of an average baby. They showed that a mother’s positive perception of her infant, as “better” than average, correlates with low risk for subsequent psychosocial problems, while her view that her infant is not better than average correlates with higher risk. In this latest follow-up, Broussard and Cassidy demonstrated that this negative effect continues right into adult life:

 

The experience of having been viewed negatively by one’s mother as a newborn, as assessed with the NPI, substantially increased the risk of insecure adult attachment. The odds of having an insecure AAI for adults whose mothers had held a negative perception of them at 1 month old were 18 times greater than for adults whose mothers had perceived them positively. (2010, p. 165).

 

These negative attributions are internalized to become a core part of the sense of self. Alicia Lieberman says that the child may become “the carriers of the parents’ unconscious fears, impulses and other repressed or disowned parts of themselves” and that “these negative attributions become an integral part of the child’s sense of self” (Lieberman, 1999, p. 737).  The child becomes literally ‘ashamed of himself’, of his or her self-agency and libido, because of the negative way these are responded to by the caregiver. I have suggested (Knox 2007) that this is the basis for the ‘fear of love’- a kind of autistic defence against relationship in those who have experienced such colonization by the disowned parts of the parental psyche.

A key question is how the baby detects such negative attributions. A one-month old baby cannot mentalize about his mother’s state of mind, cannot think ‘oh she doesn’t think I’m good enough”. What the baby does see is the caregiver’s reactions to his or her agency in the turn-taking that forms the core of human communication. A caregiver’s negative attitudes show themselves in avoidant, aversive or conflictual responses to the baby’s agency so that in the words of the BCPSG, the baby learns “what forms of affective relatedness can be expressed openly in the relationship and what forms need to be expressed only in ‘defensive’ ways, that is, in distorted or displaced forms” ((BCPSG, 2007, p. 851).

 For example, Beatrice Beebe and colleagues have found that many 4-month old infants who later show disorganized attachment have mothers who are pre-occupied with their own unresolved abuse or trauma and cannot bear to engage with their infants’ distress. Essentially, these mothers are unable to regulate their own distress, when faced with their infant’s distress and so are unable to allow themselves to be emotionally affected by their infants’ distress; they ‘shut down’ emotionally,  looking away from the infant’s face and failing to coordinate with the infant’s emotional state, a self-protective dissociation, especially around the infant’s need for comfort when distressed. (Beebe et al, 2010, p. 99).

If a mother’s face shows disappointment, fear or avoidance when she looks at her crying baby, her discordant aversive response is puzzling and distressing to her infant, as Beebe’s research and Tronick’s still face experiments have shown. Broussard and Cassidy’s demonstration of the long-term impact of early relational experience justifies us in hypothesizing that this will have profoundly damaging long-term effects on an infant’s sense of self in relationships, leading to the sense of self as bad which our patients so often describe. 

 

3) I shall now turn to the possible neuroscientific mechanisms might contribute to the  developmental and clinical phenomena I have outlined.  Firstly, there is the role of mirror neurons, found in specific parts of the cerebral cortex. The crucial characteristic that defines mirror neurons is that the same neurons fire both when carrying out an action and when observing another performing an action. Mirror neurons have different degrees of specificity, but they work together as a system to encode not just the observed actions per se, but the intention to perform those actions. So when mirror neurons fire, we know what we ourselves would intend if we performed that action and we therefore attribute the same intention to the person we observe. Mirror neuron activity provides a direct matching of the others’ observed behavior to our own motor repertoire, a neurological mirroring process that functions automatically and does not require any conscious concept or inference. This ‘mirror system’ integrates observed actions of others with an individual’s personal motor repertoire, and suggests that the human brain understands actions by motor simulation.

 Vittorio Gallese explores this mirror matching process in relation to facial expressions, showing that when people observe pictures of emotional facial expressions, they show spontaneous unconscious and rapid firing in the same facial muscles as those involved in the other person’s facial expression (Gallese, 2007, p. 149). He indicates that this rapid and automatic activation of facial muscles is probably triggered by activation of the MNS. Furthermore, an fMRI study, (Carr, Iacoboni, Dubeau, Mazziotta and Lenzi 2003) showed that both observation and imitation of the facial expression of emotions not only activate the same facial muscles but also activate the same group of brain structures, including the ventral premotor cortex, the insula and the amygdala, a mirror matching mechanism.

For example, fMRI scan show that observing disgust on another’s face activates the same parts of the insula as the participants’ direct experience of disgusting smells, suggesting that mirror-neuron activity occurs in the insula. So if the  infant’ communications are met by an expression of disgust or fear on the mother’s face, the infant’s mirror neuron system activates the corresponding networks in the baby’s insula so that he or she presumably also experiences disgust or fear directly in response to his or her own emotional states. 

But this is still not the whole story. How does this mirroring become so embedded in the child’s sense of identity, the core sense of self? How does a person come to feel that they are irredeemably bad if they seek to elicit a loving emotional response from another person? The answer I suggest may lie in the neurological links between the cortical mirror neuron system and the deeper midline structures in the brain.

Panksepp suggested that the most basic form of self  is rooted in specific midbrain neural networks, which  (Panksepp & Northoff, 2009, p. 199) are  linked to deep forebrain subcortical regions, which together  form the subcortical midline system. Panksepp describes  these mid-brain and forebrain systems  as constituting a core-SELF, the seat of specific  motivational and emotional systems common to all mammals, those of SEEKING, RAGE, LUST, CARE, PANIC, and PLAY (Panksepp, 1998; Panksepp & Panksepp, 2000).  This core-SELF (Panksepp & Northoff, 2009, p. 196) is a primitive form of consciousness, which at this level is essentially affective (emotional)

Now here is the keypoint-Ithas been suggested that the insula may be one critical relay from the mirror neuron system to the cortical and sub-cortical midline systems that underpin the core-SELF experience described by Panksepp (1998).   Other direct connections between the mirror neuron system and cortical mid-line systems (inferior parietal lobe-precuneus, mesial frontal areas- inferior frontal gyrus), form other pathways by which the two networks may interact and coordinate their activity (Rizzolatti & Luppino, 2001). These pathways may provide the route by which an expression of disgust on a mother’s face in response to her infant activates the infant’s mirror neuron response in the insula, so that the infant experiences disgust, which then directly feeds into the infant’s core-SELF system. It is a reasonable working hypothesis that this could slowly become transformed into a kind of self-hatred or self-blame- a sense of one’s own emotions and intentionality as the cause of distress, disgust or fear in another, a sense of badness at the core of one’s being.

Uddin et al. (2007) suggest that it is likely that the direct connections between the mirror neuron system and the cortical and subcortical systems integrate information that is necessary for maintaining self-other representations across multiple domains. This brings me to the default network that Ruth Lanius has described and which overlaps extensively both with mirror neuron areas, such as the inferior parietal lobe and with the cortical midline system,(CMS) for example the precuneus. Northoff and Panksepp (2008, p. 262) suggest that high degrees of self-relatedness and emotional processing correspond to high resting-state neuronal activity in the midline systems which form part of the default network.

 

The default network is a network of brain areas (comprising the posterior cingulate and precuneus, anterior cingulate and medial-prefrontalcortex, and temporoparietal junctions) which show more metabolic activity when the brain is at rest than during attention-demanding and goal-directed tasks, consuming 30% more calories for its weight than any other area of the brain (Raichle et al., 2001). The default network is active when individuals are engaged in internally focused tasks including autobiographical memory retrieval, envisioning the future, and conceiving the perspectives of others. Researchers now believe that the default network stores and updates memories based on their importance from a personal perspective and their emotional quality and returns to its sorting process whenever the brain is not engaged in an active task. So one function of the default network is to act as a constant monitor of the self and its social relationships, a self-referential processing that goes on in a resting state.

So the activity of the default network  is the process by which the brain integrates memories, emotions, and self-experience. A key contributor to this integrative work is imagination, which is attracting increasing attention from neuroscience researchers and derives from the activity of the default network. It is the activity of imagining that seems to integrate the different neural networks that contribute to self-experience. We know clinically that one consequence of trauma, is that it is precisely this capacity for imagination that is destroyed. The dissociative processes characteristic of trauma mean that memories do not become incorporated into self-experience, but intrude like alien objects into the psyche in the form of flashbacks and nightmares. Even when the trauma seems less severe, our patients also often find it far too distressing to imagine themselves back into their childhood relational experiences and it often triggers self-harm or dissociative states.

There is one final piece of neuroscience that might help explain why this is. Ruth Lanius and colleagues have shown that at rest, spontaneous low-frequency activity in the PCC/precuneus was more strongly correlated with activity in other areas of the default network in healthy controls than in patients with PTSD. In other words, patients with chronic PTSD related to early-life trauma display significantly reduced functional connectivity within the default network during the resting-state. The PCC may be a crucial node in the default network, linking past information with current environmental events and assessing these events with regard to their relevance to the self. Accordingly, Lanius and colleagues’  evidence could indicate that altered forms of self-perception and consciousness accompanying more severe and chronic PTSD derive from the greatly impaired capacity for self-referential processing of the default network in these conditions.

The reduced default network connectivity in PTSD, described by Lanius and colleagues, may explain the extraordinary difficulty people with a history of relational trauma have in developing  a more positive sense of self and so why the self-hate that I have described remains so intractable. Without the capacity for imaginative activity inherent in the default network, the patient cannot develop new stories to modify the self-hate and self-blame narratives nor imagine  new ways of seeing him or herself and  a more positive sense of self and of self-agency in relationships. In this context, one of the major tasks of therapy is to create the safe relationship within which it becomes possible to imagine and build a new sense of self.

4)Psychotherapy outcome studies.

If this working hypothesis is correct about the developmental processes and neuronal pathways that underpin the destructive long-term impact of early relational trauma on a person’s sense of self, then this would have important implications for our clinical practice. For example, we could argue that a ‘blank screen’ therapeutic style can easily replicate the same confusion, distress and shame in the patient that Tronick’s still face experiment causes the infant, or be experienced by the patient as a therapist’s aversive rejecting response to the patient’s distress, like the babies in Beebe’s study.  We know from Broussard and Cassidy (2010) that such facial responses have long-term negative effects and our adult patients are describing how this remains live for them in the here and now, through  their subjective sense of badness, self-blame and self-hate. 

So psychotherapy outcome studies are the fourth source of evidence we can use to support the hypothesis that it is real relational experience, not innate instinctual forces that determine the best treatment approach for the problems our patients bring to our consulting rooms. When researchers study the effectiveness of psychotherapy in general or compare one kind of therapy with another, a consistent finding is that psychological interventions of all kinds are better than no treatment at all—“the average treated person is better off than 80% of people who have not been treated” (Lepper & Riding, 2006, p. 9). The use of randomized controlled trials in an attempt to discover whether one type of psychotherapy can be shown to be better than another has so far failed to demonstrate any clear advantage of any one particular approach, a finding known as the Dodo effect: “Everybody has won and all must have prizes” (Lepper & Riding, 2006, p. 10; Luborsky, Singer, & Luborsky, 1975; Shedler, 2010, p. 104).         But although no one treatment approach has a clear advantage, a recently published meta-analyis by Jonathan Shedler has shown that relational factors consistently predict the outcome of psychotherapy, whatever the supposed overt theoretical model the therapist uses, from CBT to psychoanalysis- the active ingredients of therapy are not necessarily those presumed by the theory or treatment model. The more effective therapists facilitated relational processes such as a positive working alliance, enabled the patient to “experience” (focus on emotions and thoughts about self), discussed interpersonal relationships, and explored relationships with early caregivers. All these are aspects of a relational approach that also facilitates the patient’s own sense of self-agency both in relationship with the therapist and in terms of making sense of  his or her own emotions and past relational experience.

Conclusion

So I argue that when integrated with the research findings from other disciplines, neuroscience can help us to choose between our clinical theories by helping us to create the hypothesis that offers the best overall fit for the clinical phenomena we work with, including  self-harm eating disorders and dissociative states, which are usually linked to a history of early relational trauma and with which classical psychoanalytic and Jungian approaches are often largely unhelpful.

I also suggest that clinicians can also contribute to developmental and neuroscience research by a more active dialogue with neuroscientists  about some of the clinical problems that our patients bring to us, for which we urgently need to understand the neurological processes that both underpin the problems and that can contribute to developing more effective treatment approaches, based on the relational factors that actually seem to work.

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